Final Review
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?
"Your symptoms are a result of your body attacking itself."
1. A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. What clinical manifestations of fluid volume deficit? (Select all that apply.)
- Decreased skin turgor -Concentrated urine i -Low-grade fever -Tachypnea
2. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. What clinical manifestations are indicative of fluid volume excess? (Select all that apply.)
- Dyspnea -Edema - Hypertension - Weaknessy
3. A nurse is caring for a client who is dehydrated. What clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?
- Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of fluid volume deficit
Isotonic
-D5W -D5 1/4 NS -NS-0.9% NaCl -Lactated Ringer's Solution -10% Dextran 40 in 5% Dextrose -10% Dextran 40 in 0.9% NS
The nurse is conducting allergy skin testing on a client. What postprocedure interventions are most appropriate?
-Record site, date, and time of the test. -Give the client a list of potential allergens if identified.
A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions?
-administer oxygen -quickly assess the client's respiratory status -document the event, interventions, and client's response
A nurse interventions for an allergic reaction would be:
-identification of the specific allergy -Management of the symptoms with antihistamines, anti-infammatory agents, and/or corticosteroids -ointments, creams, wet compresses, and soothing baths for local reactions. -Desensitization programs.
Priority nursing actions for an anaphylactic reaction
-quickly assess respiratory status and maintain patient's airway -call provider and rapid response team -Administer oxygen -Start IV line and infuse normal saline -prepare to administer diphenhydramine and epinenphrine -document the event, actions taken, and the client's response
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?
0.45% sodium chloride
Which is considered an isotonic solution?
0.9% normal saline
The nurse is assigned to care for a group of clients. On review of the medical records, the nurse determines that which client is most likely at risk for fluid volume deficit? 1 - A client with an ileostomy 2 - A client with heart failure 3 - A client on long term corticosteroid therapy 4 - A client receiving frequent wound irrigations
1 - A client with an ileostomy Reason: - Ileostomy = stoma created in the ileum and brought to the surface of the abdomen - Increases fluid deficit risk
The nurse reviews a client's lab report and notes the serum phosphorus level is 2mg/dL. Which condition most likely caused this level? 1 - Alcoholism 2 - Renal insufficiency 3 - Hypoparathyroidism 4 - Tumor lysis syndrome
1 - Alcoholism Reason: - Normal phosphorus levels: 2.7 - 4.5 mg/dL - This patient is HYPOphosphatemic - A cause of this would be malnutrition (a common factor associated with alcoholism)
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note? 1 - twitching 2 - Hypoactive bowel sounds 3 - Negative Trousseau's sign 4 - Hypoactive deep tendon reflexes
1 - Twitching Reason: - This is a common finding in hypocalcemia
The nurse caring for a group of clients reviews the electrolyte lab results and notes a sodium level of 130 mEq/L on one lab report. The nurse understands that which client is at the highest risk for development of this sodium level value? 1 - the client taking diuretics 2 - the client with hyperaldosteronism 3 - the client with Cushing's Syndrome 4 - the client taking corticosteroids
1 - the client taking diuretics Reason: - Normal sodium levels: 135 - 145 mEq/L - This patient is HYPOnatremic - Most times salt follows water, so diuretics cause loss of Na as well
Which of the following is the most severe form of hypersensitivity reaction?
Anaphylaxis
A nurse is teaching a client about the risk for cancer. Which of the following client statements indicates the need for further teaching? A "I see a dermatologist regularly for the mole on my thigh." B. "I take Milk of Magnesia for occasional constipation." C. "I tan using an indoor tanning lotion instead of laying out in the sun." D. "I used to smoke but switched to chewing tobacco 3 years ago."
D. "I used to smoke but switched to chewing tobacco 3 years ago."
The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration?
Extravasation of the medication
isotonic solutions are used for
FVD, hemmorhage, D/V
Which of the following nursing interventions is appropriate with regard to pain control in the dying client?
Give pain medications on a routine schedule.
A benign tumor of the blood vessels is a(n)
Hemangioma
Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?
Histamine
A client is diagnosed with a terminal illness and has been given less than 6 months to live. What type of referral should the nurse make to assist this patient and family at home?
Hospice
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?
Hypercalcemia
5. A nurse is assessing a client who has hyperkalemia. What conditions are associated with this electrolyte imbalance?
Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with diabetic ketoacidosis.
The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
Hypocalcemia Explanation: You can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek sign.
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia
hypotonic solutions are used for
Intracellular dehydration
4. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. What actions should the nurse take?
It is an appropriate action for the nurse to monitor the client's respiratory status and for shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right lower lobe. This client is dehydrated and has fluid volume deficit.
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy?
It removes a wedge of tissue for diagnosis.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?
Limit sodium and water intake. Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care?
Limit the time that visitors spend at the client's bedside.
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications.
Which is a correct route of administration for potassium?
Oral
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?
Passive immunity transferred by the mother
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?
Place the client in a private room.
The nurse is assisting in planning care for a client diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care
Protecting the client from infection
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells them to consume which of the following (select all that apply)? 1 - Peas 2 - Raisins 3 - Potatoes 4 - Cantaloupe 5 - Cauliflower 6 - Strawberries
Raisins, Potatoes, cantaloupe, strawberries
1. A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. What treatments can result in these laboratory findings?
Receiving three tap water enemas can result in a decrease in serum sodium and potassium in the client. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.
Palliation refers to
Relief of symptoms of disease and promotion of comfort and quality of life.
When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?
Risk for infection related to altered immune cell function
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel
A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?
Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.
The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
Supporting the client's and family's values and choices
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
Tachycardia .
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?
The immune system recognizes one's own tissues as "foreign."
2. A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for what clinical manifestations?
The nurse should assess the client for ECG changes. Potassium levels can affect the heart and result in arrhythmias.
3. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for what electrolyte imbalances?
The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium.
4. A nurse is assessing a client for Chovstek's sign. What techniques should the nurse use to perform this test?
The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of his face.
The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposis Sarcoma Lesions. The Lesions are open and draining a scant amount of serous fluid. What should the nurse incorporate in the plan during the bathing of this client?
Wearing a gown and gloves R
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client record and determines that the client was at risk for developing the potassium deficit because of which situation? 1 - Sustained tissue damage 2 - Requires nasogastric suction 3 - Has a history of Addison's disease 4 - Is taking potassium-retaining diuretics
2 - Required nasogastric suction
The nurse is assigned to care for a group of clients. On review the nurse determines that which client is at risk for fluid volume excess? 1 - The client taking diuretics 2 - The client with kidney disease 3 - The client with an ileostomy 4 - The client who required GI suctioning
2 - The client with kidney disease Reason: - This is a cause of fluid volume excess
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Clamp the Penrose drain. 2. Change the dressing as prescribed. 3. Notify the health care provider (HCP). 4. Remove and replace the perineal packing.
2. Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore the nurse should change the dressing as prescribed.
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect in hyponatremia? 1 - Muscle twitches 2 - Dec urinary output 3 - Hyperactive bowel sounds 4 - Increased specific gravity of urine
3 - Hyperactive bowel sounds
The nurse is caring for a client with heart failure. On Assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1 - weight loss 2 - Flat neck and head veins 3 - An increase in BP 4 - Decreased central venous pressure
3 - Increase in BP
The nursing student needs to administer potassium chloride IV as prescribed to client with hypokalemia. The instructor determines that the student is unprepared if the student states that which action is part of the plan for preparation and administration of the potassium? 1 - obtaining IV infusion pump 2 - Monitoring urine output during administration 3 - Preparing the medication for bolus administration 4 - Ensuring the med is diluted in the appropriate amount of normal saline
3 - Preparing for bolus administration Reason: - Bolus = IV push - Potassium is NEVER given by IV push (AKA bolus)
The nurse is caring for a client with hypocalcemia would expect to note which change to the ECG? 1 - Widened T wave 2 - Prominent U wave 3 - Prolonged QT interval 4 - Shortened ST segment
3 - Prolonged QT interval reason: - ECG findings in hypocalcemia include: prolonged QT interval and prolonged ST segment
The nurse caring for a client who has been receiving IV diuretics suspects they are experiencing fluid volume deficit. Which assessment finding would the nurse note in this condition? 1 - Lung congestion 2 - Decreased hematocrit 3 - Increased BP 4 - Decreased central venous pressure
4 - Decreased central venous pressure Reason: This is a finding in fluid volume deficit
The nurse is reviewing lab results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the level to the health care provider and they prescribe dietary instructions based on the sodium level. Which food does the client need to avoid? 1 - Peas 2 - Nuts 3 - Cauliflower 4 - Processed oat cereals
4 - Processed oat cereal Reason: - Normal levels: 135 - 145 mEq/L - The patient has an elevated level meaning they should not consume sodium rich foods, and processed foods have elevated amounts of sodium
The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the ECG as a result? 1 - ST depression 2 - Inverted T wave 3 - Prominent U wave 4 - Tall peaked T wave
4 - Tall peaked T wave Reason: - Normal potassium levels: 3.5 - 5.0 mEq/L - This patient is HYPERkalemic meaning the ECG results would be: tall peaked T waves, flat P waves, widened QRS complex, prolonged PR interval
RBC
4-5 million
WBC
4500-11000 (4.5-11)
A nurse is teaching a client about maintaining a diet that may prevent certain cancers. The nurse should inform the client that the intake of which of the following may be beneficial? (SATA) A. Low saturated fats B. Fiber C. Red meats D. Simple carbohydrates E. Fish
A. Low saturated fats B. Fiber E. Fish
A nurse has given a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?
Active acquired immunity
A nurse is planning care for a client who is scheduled for genetic testing for suspected cancer. Which of the following interventions should the nurse include in the plan of care? A. Obtain a signed informed consent form. B. Withhold all medications prior to the procedure. C. Verify the prescription for a tumor marker assay. D. Ensure the client is placed in a recovery position after testing.
A.Obtain a signed informed consent
A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing?
Acceptance
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."
Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity.
A nurse is teaching a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse give? A. "The presence of a liver enzyme will be identified." B. "you will be given an injection of a radioactive substance." C."An endoscope will be inserted through your mouth." D."The tumor will be aspirated."
B. "you will be given an injection of a radioactive substance."
A nurse is reviewing the laboratory findings of a client who has a WBC count of 20,000/mm^3. Based on these findings, the nurse should conclude that the client has which of the following? A. Neutropenia B. Leukocytosis C. Hemolysis D. Leukopenia
B. CORRECT: Leukocytosis is a WBC count of greater than 10,000/mm^3, which can indicate an inflammatory response to a pathogen or a disease process.
A nurse is preparing to administer a scratch test to a client who has suspected food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (Select all that apply.) A. Cleanse the client's skin with povidone-iodine (Betadine). B. Ask the client about previous reactions to allergens. C. Ask the client about medications taken over the past several days. D. Inform the client to expect itching at one site. E. Obtain emergency resuscitation equipment
B. CORRECT: The nurse should ask the client about any previous reactions to allergens, which could indicate an increased risk of an anaphylactic reaction. C. CORRECT: The nurse should ask the client about medications taken over the past several days. Antihistamines and corticosteroids should not be taken within the past 5 days due to their ability to suppress reactions. D. CORRECT: Histamine will be applied as a control site so the client will experience itching at this site. E. CORRECT: Emergency equipment should be available, even if the client denies experiencing an anaphylactic reaction.
A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? A. Encourage a high‐fiber diet. B. Remove plants from the room. C. Have the client wear a mask when leaving the room. D. Have client‐specific equipment remain in the room. E. Eliminate raw foods from the client's diet
B. Remove plants from the room. C. Have the client wear a mask when leaving the room. D. Have client‐specific equipment remain in the room. E. Eliminate raw foods from the client's diet
A nurse is assessing a client for suspected cancer. Which of the following findings should the nurse expect? A. Temperature 102° F (38.9° C) for more than 48 hr B. Sore that does not heal C. Difficulty swallowing D. Unusual discharge E. Weight gain 4 lb (1.8 kg) in 2 weeks
B. Sore that does not heal C. Difficulty swallowing D. Unusual discharge
A nurse is caring for a client who has cancer. The goal of palliative pain management is to increase which of the following? (Select all that apply.) A.Mental acuity B.Physical mobility C.Time spent at home D.Quality of life E.Bowel function
B.Physical mobility C.Time spent at home D.Quality of life
A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant melanoma? A. Diffuse vesicles B. Uniformly colored papule C. Area with asymmetric borders D. Rough, scaly patch E. Irregular colored mole
C. Area with asymmetric borders E. Irregular colored mole
A nurse is reviewing the laboratory findings of a client who has the measles. The nurse should expect to find an increase in which of the following types of WBCs? A. Neutrophils B. Basophils C. Monocytes D. Eosinophils
C. CORRECT: Monocytes are increased when a viral infection such as measles occurs and chronic inflammation is present.
A nurse is teaching a female adult client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to have a mammogram every 2 years beginning at age 45." B. "I should have a colonoscopy every 15 years beginning at age 60." C."I will need to have an annual breast examination every year after 40." D."I should have a fecal occult test done every 3 years."
C."I will need to have an annual breast examination every year after 40."
A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C."Try eating several small meals throughout the day." D."Increase your intake of red meat as tolerated."
C."Try eating several small meals throughout the day."
The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met?
Client identifies methods for reducing exposure risk to allergens.
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
Communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact. Explanation: The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact. Nodding, responsive comments such as "Yes" or brief periods of silence encourage the client to continue verbalizing. Calling out to the client's family members and asking them to sit next to the client may not be the best intervention. It is important for nurses to be flexible and to interrupt physical care if and when the client indicates a need for companionship, support, and communication. This client is seeking companionship and communication, not rest.
The nurse is evaluating bloodwork results of a client with cancer who is receiving chemotherapy. The client's platelet count is 60,000/mm3. Which is an appropriate nursing action?
Correct response: Avoiding the use of products containing aspirin
A nurse is teaching a client who is scheduled for a shave biopsy for suspected cancer. Which of the following client statements indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C."A needle will be inserted into the mass." D."A small skin sample will be obtained."
D."A small skin sample will be obtained."
This solution can be isotonic and hypertonic
D5W
The nurse is caring for a client with laboratory values indicating dehydration. What clinical symptom is consistent with the dehydration?
Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?
Delayed hypersensitivity response
The nurse assesses that extravasation of a chemotherapy agent has occurred. What is the nurse's initial action?
Discontinue the infusion.
10% Dextran 40 in 0.9% NS
isotonic
Lactated Ringer's Solution
isotonic
NS 0.9% NaCl (normal saline
isotonic
Hypercalcemia
isotonic (0.9 NaCl)
During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses:
acquired immunity.
A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis?
administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
Hyponatremia
isotonic fluids: Lactated ringers and 0.9 NaCl
Hypovolemia
isotonic fluids: Lactated ringers and 0.9 NaCl
3% NS
hypertonic
Hyperkalemia
hypertonic solution or regular insulin
Hypertonic solutions are used for
hypo Na+, Cerebral edema
1/2 NS (0.45% NaCl)
hypotonic
Hypernatremia
hypotonic (0.45 NaCl) or isotonic (NS 0.9 NaCl)
The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis?
intradermal testing